The Revised Joint Comission Standards

New Joint Commission ‘Revised Requirements for Diagnostic imaging Services’ (USA) expect more from hospitals concerning radiology dose. Effective July 1st, 2015, hospitals must track, record, and improve X-ray dose performance against external benchmarks. In Europe, new regulations are expected to be in place by 2018.

While the July 1st deadline is just around the corner, your hospital still has time to prepare if you start now. Failure to meet these standards may have potential repercussions, including accreditation risk and associated revenue loss.

“There are several strategies hospitals can employ today to avoid a costly and resource-consuming scramble at the last minute.”

Dominic Siewko, Clinical Marketing Manager, Philips Healthcare

Joint Commission Standards Gap Analysis Tool

Conducting a gap analysis is a key step in developing and improving your dose management program to assist your organization in complying with Joint Commission requirements. We’ve developed a useful tool to help you compare your current practices against these new requirements and define corrective action.

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Radiation safety standards*

The Joint Commission has proposed some significant radiology process flow and quality performance standards that may require new ways of working for some healthcare providers, specifically regarding education requirements, equipment calibration, and data review. We’ve selected and summarized the key elements below and offered some insight into what you might consider.

Document radiation dose index by exam and by machine
Document radiation dose index by exam and by machine

The requirement states, “The [critical access] hospital documents in the patient’s record the radiation dose index (CTDIvol, DLP, or size-specific dose estimate [SSDE]) on every study produced during a diagnostic computed tomography (CT) examination. “

In addition to the Joint Commission standards, some States have their own radiation dose regulations and adhering to these requirements can be a challenge. A recent study** suggests that relying primarily on human performance does not ensure accurate dose reporting and may actually lead to compliance errors.

Establishing a better defined, more reliable reporting process may include use of an automated dose reporting system to improve compliance. Most importantly, your clinicians need actionable data to make informed decisions about the right radiation dose for each patient.
Review and analyze dose data
Review and analyze dose data

The requirement states, “The [critical access] hospital reviews and analyzes incidents where the radiation dose index (CTDIvol, DLP, or size-specific dose estimate [SSDE]) from diagnostic CT examinations exceeded expected dose index ranges identified in imaging protocols. These incidents are then compared to external benchmarks.”

Reviewing and analyzing dose data is critical to identifying your current dose management strengths and weaknesses. Analysis by exam type, patient type, and staff preferences will uncover opportunities for improvement. Use an automated tool to do this for each and every one of your radiation emitting imaging systems and you’ve begun the move toward proactive change.
Identify and review dose metrics that exceed expected ranges
Identify and review dose metrics that exceed expected ranges

The requirement states, “The [critical access] hospital reviews and analyzes incidents where the radiation dose index (CTDIvol, DLP, or size-specific dose estimate [SSDE]) from diagnostic CT examinations exceeded expected dose index ranges identified in imaging protocols. These incidents are then compared to external benchmarks.”

Measuring and analyzing your radiation dose across your equipment portfolio is the first step. The second is establishing Diagnostic Reference Levels (DRLs) to make sure you are targeting a realistic and low dose in accordance with ALARA principles.
Compare data with external benchmarks for each X-ray machine
Compare data with external benchmarks for each X-ray machine

The requirement states, “The [critical access] hospital reviews and analyzes incidents where the radiation dose index (CTDIvol, DLP, or size-specific dose estimate [SSDE]) from diagnostic CT examinations exceeded expected dose index ranges identified in imaging protocols. These incidents are then compared to external benchmarks.”

The Joint Commissions requirements seek to ensure efforts are standardized across the industry and that health systems are following ‘best practices’. Using Diagnostic Reference Levels you can benchmark yourself against other healthcare providers and proactively mitigate radiation exposure for your patients and staff.
Review and keep CT imaging protocols current with accepted standards
Review and keep CT imaging protocols current with accepted standards

The requirement states, “Diagnostic computed tomography (CT) imaging protocols are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice and account for changes in CT imaging equipment. These reviews are conducted at time frames identified by the organization.”

By maintaining strong imaging protocols you can more easily customize exams using the low possible dose for your clinical purposes.

Be a leader in dose management

The end goal for all of these requirements is to drive toward a more individualized treatment plan for patients, review and analyze dose data, and benchmark your facility against peers. Adhering to these requirements in clinical practice will help establish a cornerstone for an effective radiation protection program in your radiology department.

* Joint Commission Revised Requirements for Diagnostic Imaging Services. Issued January 9, 2015. Effective July 1, 2015

** Zucker, Evan J., et al, Radiologist Compliance With California CT Dose Reporting Requirements: A Single-Center Review of Pediatric Chest CT, American Roentgen Ray Society, AJR:204, April 2015

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Are you ready for the new standards?

“There are several strategies hospitals can employ today to avoid a costly and resource-consuming scramble at the last minute.”

Joint Commission Standards Gap Analysis Tool

Radiation safety standards*

Be a leader in dose management

Are you ready for the

new standards?